Behaviour and toileting

Expert: Paediatric OT Jenni Machin

Jenni Machin is an Occupational Therapist with more than thirty years’ experience. During this time Jenni has worked in the areas of multiple and complex disability, cerebral palsy, learning and language disorders and autism spectrum disorder. Her particular interests are behaviour management and sensory processing.

Currently Jenni is the National Coordinator of the HCWA funded Early Days workshops, delivering free workshops to the families of young children with or suspected to have ASD. She also manages the HCWA Aboriginal and Torres Strait Islander Liaison Officer project which is increasing ASD awareness amongst the indigenous community.

Q&A with Jenni Machin

Q: What is the earliest to start toilet training? I have heard talk of children as young as 6 months of age as being introduced to the toilet. Is there an ideal age where children are at the appropriate age to teach good toileting behaviour?

True toilet training requires an understanding of cause and effect; with basic understanding skills for toileting beginning at 18 months and being established around 36 months. Children younger than this do not have the cognitive skills for toilet training, nor the motor or sequencing skills to get independently to the toilet and remove their clothing. Younger children may be able to develop ‘toilet timing skills’ that is reasonable success on the toilet or potty if taken at regular intervals and with consistent frequency but it is not independent toileting.

Interestingly, some children who are ‘toilet timed’ quite young have difficulty moving to complete toileting independence later on as they have become very reliant on the adult interactions that ‘toilet timing’ requires. If this occurs, it is important for the adult to think about the amount of time they have been spending in the toileting process with their child and spend that same amount of time in an activity during the day the child will really enjoy.

In short the best time to toilet train is between 18-36 months.

Q: I work in continence management and often get questions from parents who have children starting school soon that have not been toilet trained. A lot of the problem I think comes from the parents behaviour and attitude towards toilet training. Can you suggest any subtle but effective ways to teach parents to toilet train their primary school aged child?

It is concerning that this is a bit of an emerging trend – in some countries as many as 10 per cent of primary school-aged children are not toilet trained.

Basic toileting strategies for school-aged toilet training are the same as for younger children. But changing the toileting behaviour at this late stage will require a clear plan of action, and consistency by everyone concerned, including school staff.

Some parents feel the responsibility for toilet training lies with child care staff and educators, and not necessarily with them. Therefore, involving another professional to establish a toilet training schedule, and monitoring the progress of these families can be more helpful than asking these families to ‘go it alone’.

Another cause may be that the child has developmental or sensory differences that reduce their awareness or cognitive link to toileting. For these children, approaches such toilet timing, visual supports for each of the toileting steps, and sensory strategies to increase their awareness of fullness and muscle control for conscious elimination can help. (Toilet training app link may go in here)

If the child does not have developmental or sensory issues, then behavioural factors need to be considered. It’s important to try to understand why toileting this way makes it worthwhile for the child. For example, how are others responding when the child is wet or soiled? Does the child get one-on-one time with mum or dad after toileting accidents? Are the reactions of others to toileting accidents getting them some predictable interactions - even if they are not positive? Do they always get a bath or shower after the fact?

Another consideration is the investment the parents have in their child not being trained. Counselling for families reluctant to toilet train their child can be important in shifting the responsibility of their child’s toilet training from others back to the parents.

Q: What are some strategies I can use with my clients who refuse to poo unless a nappy is on?

There are many reasons why children will only poo in a nappy.

Some active children think sitting to poo takes too long. For these children, encourage them to sit on the toilet for 3 to 5 minutes when they’re most likely to poo, which is usually first thing in the morning and 10 to 30 minutes after a meal.

It may be that the child likes the secure, firm feel of the nappy on their lower tummy, and the pressure may actually help the poo move through the bowel. Some other children like the feeling of the poo sitting in their pants. In these cases, have the child wear underpants under the nappy (or pull-up) and gradually loosen the nappy (or tear the side of the pull-up) over time until it’s so loose it no longer stays up, leaving just the underpants.

Some children prefer to stand or squat to poo. The position is important in elimination, so ensure the toilet has a solid foot stool large enough for the child to stand and turn around on, and high enough for their hips, knees and ankles to be bent at 90 degree angles or greater. Encourage the child to lean forward, and to blow out their mouths if they want to help move the poo. Some families use a potty to facilitate the squat position, placing the potty in or near the toilet.

Some families just go cold turkey - no more nappies. This can work but it can also backfire. I have known children who have held their bowel motions for so long it has become impacted and hospitalisation has been required. This method should be tried with caution and careful monitoring.

Q: I have a client with a 4-year-old child who is doing poo in his bedroom, he has control and will toilet appropriately when out of home but has not responded to parental efforts or reward strategies tried previously. He is involved with the child development team as he has delay in some areas such as speech and fine motor skills. We have tried praise, stickers, sweets, toys etc. with no results. He tends to do his poo in the morning anywhere between 5-8am when he first wakes and before others are up in the house. He has been involved in cleaning up too. Any suggestions for a particularly persistent issue?

I think the fact he likes the quiet, private environment of his bedroom is significant, as this may make him feel calm, making it is easier to poo.

If he is pooing in his pants or nappy, I suggest putting him in undies or pull-ups and placing a potty in the bedroom. Put a picture above the potty reminding him what to do (for example, a picture of pants or pull-ups with a red cross through it, and an arrow pointing to a potty with a smiley face).

Once the child is using the potty in the bedroom the potty is moved towards, and finally into the toilet, but the picture should remain where he sees it when he first awakes.

It may also help to write a story the child can relate to that explains poo, why it usually comes out in the morning and why it needs to be dumped – like a rubbish dump truck. The video [i]Tom’s Toileting Triumph[/i] explains pooing well.

If he is still wearing nappy to bed and likes to poo in his nappy in the morning, the strategies outlined in the response to Q4 may help.

Q: How can you teach a child to use the toilet if they're scared of the loo?

Phobias are common in young children – toilet fear can be associated with the look/smell/ sound of toilet, the fear of falling in or off, the sound of the toilet flush, not being able to get on and off easily, not feeling comfortable when the poo falls and/or not understanding that poo is separate from them. An adult’s loud reverberating voice in the toilet, even if it’s encouraging, can be frightening for a child. Some children have experienced the painful passing of poo or urine.

It is important to address all these possible issues and set up an environment for success. It also helps to have your child assist in setting up a shelf or small basket with toys or books for the toilet, and decorate the room with friendly stickers or posters.

Encourage short frequent trips to the toilet, even if it’s just to sit on the toilet with no expectation of doing anything (make sure the toilet has a seat insert, a stool or step-up with frame so he can adopt the correct posture). Then gradually lengthen the time on the toilet and align it with the time the child is most likely to wee or poo.

For children who do not like the feeling of the poo dropping from their bottoms, try positioning plastic cling wrap loosely across the toilet (under the seat) so the poo does not drop so far. Gradually lower the cling wrap so the child becomes used to the feeling of the poo dropping. This can also be done with a nappy.

Writing a story for the child that explains poo is a waste product that our body does not need is another suggestion. Include in the story characters or ideas that the child can relate to.